Combined Orbital Fractures: Surgical Strategy of Sequential Repair

BACKGROUND: Reconstruction of combined orbital floor and medial wall fractures with a comminuted inferomedial strut (IMS) is challenging and requires careful practice. We present our surgical strategy and postoperative outcomes. METHODS: We divided 74 patients who underwent the reconstruction of the orbital floor and medial wall concomitantly into a comminuted IMS group (41 patients) and non-comminuted IMS group (33 patients). In the comminuted IMS group, we first reconstructed the floor stably and then the medial wall by using separate implant pieces. In the non-comminuted IMS group, we reconstructed the floor and the medial wall with a single large implant. RESULTS: In the follow-up of 6 to 65 months, most patients with diplopia improved in the first-week except one, who eventually improved at 1 year. All patients with an EOM limitation improved during the first month of follow-up. Enophthalmos (displacement, 2 mm) was observed in two patients. The orbit volume measured on the CT scans was statistically significantly restored in both groups. No complications related to the surgery were observed. CONCLUSIONS: We recommend the reconstruction of orbit walls in the comminuted IMS group by using the following surgical strategy: usage of multiple pieces of rigid implants instead of one large implant, sequential repair first of the floor and then of the medial wall, and a focus on the reconstruction of key areas. Our strategy of step-by-step reconstruction has the benefits of easy repair, less surgical trauma, and minimal stress to the surgeon.

Penile Reconstruction after Extensive Excision of Sclerosing Lipogranuloma: How to Make the Shape of Scrotum, Penile Shaft and Suprapubic Region with a Rectangular Radial Forearm Free Flap

The authors had five cases of penoplasty from more than half of the scrotum to the suprapubic region using a fasciocutaneous radial forearm free flap (RFFF) after extensive excision of sclerosing lipogranuloma. Although the harvested RFFF was a rectangular shape, the authors made the shape of scrotum, penile shaft, and suprapubic region by using well designed geometry and several quilting sutures on junction of scrotum and penis. The contour of scrotum and penis was well maintained, and there were no complications, such as scrotal contracture, penile deformity, and erectile dysfunction during the one year follow up period in all five cases. There were no recurrent lesions and no need for further surgery.

Management of the Accidental STSG Donor Site Injury: Case Reports

When the split thickness skin graft (STSG) was harvested from the patient's posterior thigh in supine position, an accidental donor site injury could occur by postural instability with the raised leg of patient. The idea of partial return of the harvested graft to the donor site, spraying fibrin sealant and using skin fragments have been individually introduced as the management of donor site injury created during harvest of the STSG. However, in our knowledge, there has been no attempt to combine the three ideas and apply to the accidental STSG donor site injury. We present the fragments regraft technique, with deliberately leaving some of harvested skin, cutting the remnant skin into small pieces, and immediately returning the skin fragments by spraying fibrin sealant on the damaged donor site wound. This method could be considered as a treatment option to prevent delayed wound healing of STSG donor site injury, especially when elderly or debilitated patients who are suspected of a delayed wound healing and poor-quality skin.

Venous Occlusion Detected by Caregiver with Implantable Doppler in a Buried Free Flap

The use of the implantable Doppler device eases the burden of free flap monitoring, and allows caregivers to notify healthcare personnel of a potential vascular event. A 24-year-old female patient underwent anterolateral thigh adipofascial flap surgery to provide a buried flap on the left temporal area for a depressed and infected skull wound. The author was able to salvage the flap from two venous occlusions, which was made possible by early notifications from the caregiver who reported changes in the Doppler signal.